Healthcare Provider Details

I. General information

NPI: 1295875318
Provider Name (Legal Business Name): MARK SHIGEOKA D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 CALIFORNIA AVE STE 204
WAHIAWA HI
96786-1841
US

IV. Provider business mailing address

302 CALIFORNIA AVE STE 204
WAHIAWA HI
96786-1841
US

V. Phone/Fax

Practice location:
  • Phone: 808-622-2633
  • Fax: 808-622-2342
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDT-1137
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: